cma drivers guide

7/28/2019 CMA Drivers Guide

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CMA Drivers GuideDetermining Medical Fitness to Operate Motor Vehicles 8th editio


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2012 Canadian Medical Association

Please note that the CMA is a member of Access Copyright, The Canadian Copyright Licensing Agency (formerlyknown as CANCOPY). As such, we have an agreement in place with ACCESS to grant to organizations and individuals,

on our behalf, permission to make photocopies from our publications. Should you wish to pursue this request, we askthat you contact ACCESS COPYRIGHT, THE CANADIAN COPYRIGHT LICENSING AGENCY, 800One

Yonge Street, Toronto ON M5E 1E5 Tel 416 868-1620; 800 893-5777; fax 416 868-1621 or visit their website:www.accesscopyright.ca

Published by the Canadian Medical Association

Library and Archives Canada Cataloguing in Publication

CMA driver's guide [electronic resource] : determining medical fitness

to operate motor vehicles. -- 8th ed.

Issued also in French under title: valuation mdicale de l'aptitude conduire.

Includes bibliographical references.Electronic monograph in PDF format.Issued also in print format.ISBN 978-1-897490-16-7

1. Automobile driving--Physiological aspects--Handbooks, manuals,etc. 2. Automobile drivers--Medical examinations--Handbooks, manuals,

etc. 3. Automotive medicine--Handbooks, manuals, etc. I. CanadianMedical Association

TL152.35.D47 2012 629.28'302461 C2012-907924-3

Disclaimer: This guide is not a substitute for medical diagnosis, and readers are encouraged to use their best clinicaljudgement to determine a patients medical fitness to drive. The naming of any organization, product or alternativetherapy in this book does not imply endorsement by the Canadian Medical Association, nor does the omission of anysuch name imply disapproval by the Canadian Medical Association. The Canadian Medical Association does notassume any responsibility for liability arising from any error in or omission from the book, or from the use of anyinformation contained in it.

galement disponible en franais.

Free to CMA members online at cma.ca/driversguide


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Drivers Guide 8th EditionContents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Section 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 A guide for physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Functional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 Medical standards for fitness to drive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.4 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.5 The physicians role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.6 Public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.7 Levels of medical fitness required by the motor vehicle licensing authorities . . . . . . . . . . . . . . . 41.8 Drivers medical examination report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.9 Physician education on driver evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.10 Payment for medical and laboratory examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.11 Classes of drivers licences and vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.12 Contact us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Section 2: Functional assessment emerging emphasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.2 Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.3.1 Office assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.3.2 Functional assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Section 3: Reporting when and why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103.2 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113.3 Patients right of access to physicians report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Section 4: Driving cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.2 Voluntary driving cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.3 Involuntary driving cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144.4 Planning for retirement from driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154.5 Strategies for discussing driving cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

4.6 Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Section 5: Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

5.2.1 Clinical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.2.2 Screening tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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Section 6: Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206.2 Clinical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216.3 Common drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

6.3.1 Sedatives and hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .216.3.2 Non-prescription antihistamines, motion-sickness medications

and muscle relaxants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216.3.3 Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216.3.4 Central nervous system stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.5 Hallucinogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.6 Inhalants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.7 Antidepressants and antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.8 Anticonvulsants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.9 Conscious sedation in an outpatient setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.10 Anti-infective agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226.3.11 Anticholinergics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236.3.12 Designer drugs and herbal preparations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

6.3.13 Antiparkinsonian drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236.4 Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Section 7: Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247.2 Hidden Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257.3 Multiple comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Section 8: Dementia and mild cognitive impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288.2 Canadian guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

8.3 Reporting according to stage of dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298.4 Special problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298.5 Cognitive screening tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8.5.1 Use tests in the context of more detailed approaches . . . . . . . . . . . . . . . . . . . . . . . . . 318.6 When fitness to drive remains unclear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318.7 Counselling patients with dementia who can still drive safely . . . . . . . . . . . . . . . . . . . . . . . . . 32

Sleep 9 Sleep disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339.3 Obstructive sleep apnea (OSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

9.3.1 Driving recommendations for patients with OSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 349.4 Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

9.4.1 Driving recommendations fornarcoleptic patients . . . . . . . . . . . . . . . . . . . . . . . . . . 359.5 Other sleep disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Section 10: Psychiatric illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3610.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3610.2 Functional impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3710.3 Assessing fitness to drive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

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10.4 Specific illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3810.4.1 Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3810.4.2 Personality disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3810.4.3 Depression and bipolar disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3810.4.4 Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3910.4.5 Psychotic episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

10.4.6 Attention deficit hyperactivity disorder (ADHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3910.4.7 Aggressive driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3910.5 Psychoactive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Section 11: Nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111.2 Febrile or toxic seizures, benign childhood absence epilepsy

and other age-related epilepsy syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111.3 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111.4 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

11.4.1 Single, unprovoked seizure before a diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

11.4.2 After a diagnosis of epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4311.4.3 After surgery to prevent epileptic seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4411.4.4 Seizures only while asleep or on wakening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4411.4.5 Withdrawal of seizure medication or medication change . . . . . . . . . . . . . . . . . . . . . 4411.4.6 Auras (simple partial seizures) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4511.4.7 Seizures induced by alcohol withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

11.5 Disorders affecting coordination, muscle strength and control . . . . . . . . . . . . . . . . . . . . . . . . . 4511.6 Severe pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4611.7 Head injury and seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

11.7.1 Post-traumatic seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4611.7.2 Post-traumatic epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

11.8 Intracranial tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4711.8.1 Benign tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4711.8.2 Malignant tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

11.9 Parkinsons disease and parkinsonism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Section 12: Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4812.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4812.2 Recommended visual functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

12.2.1 Visual acuity (corrected) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4912.2.2 Visual field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4912.2.3 Diplopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

12.3 Other important visual functions for driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5012.3.1 Colour vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5012.3.2 Contrast sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5012.3.3 Depth perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5012.3.4 Dark adaptation and glare recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

12.4 Exceptional cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50Addendum 1: Testing procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Addendum 2: Medical conditions and vision aids for driving . . . . . . . . . . . . . . . . . . . . . . . . . 52

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Section 13: Auditory-vestibular disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5313.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5313.2 Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

13.2.1 Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5313.2.2 Hearing assistive devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

13.3 Vestibular disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

13.3.1 Acute unilateral vestibular dysfunction single prolonged episode . . . . . . . . . . . . . 5413.3.2 Recurrent unilateral vestibular dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5413.3.3 Chronic bilateral vestibular hypofunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Section 14: Cardiovascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5514.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5514.2 Coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

14.2.1 Acute coronary syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5614.2.2 Stable coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5614.2.3 Cardiac surgery for coronary artery disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

14.3 Cardiac rhythm, arrhythmia devices and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

14.3.1 Ventricular arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5714.3.2 Paroxysmal supraventricular tachycardia, atrial fibrillation or atrial flutter . . . . . . . . 5714.3.3 Persistent or permanent atrial fibrillation or atrial flutter . . . . . . . . . . . . . . . . . . . . . 5714.3.4 Sinus node dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5814.3.5 Atrioventricular and intraventricular block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5814.3.6 Permanent pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5814.3.7 Implantable cardioverter defibrillators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5914.3.8 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.4 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6014.5 Valvular heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

14.5.1 Medically treated valvular heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

14.5.2 Surgically treated valvular heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6114.6 Congestive heart failure, left ventricular dysfunction, cardiomyopathy, transplantation . . . . . . 6114.7 Hypertrophic cardiomyopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6214.8 Cardiac rehabilitation programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6214.9 Implantation of Left Ventricular Assist Device (LVAD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6214.10 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6314.11 Abnormal blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

14.11.1 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6314.11.2 Hypotension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

14.12 Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Section 15: Cerebrovascular diseases (including stroke) . . . . . . . . . . . . . . . . . . . . . . . . . . . 6515.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6515.2 Transient ischemic attacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6515.3 Cerebrovascular accidents(stroke) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

15.3.1 Brain aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6515.3.2 Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

15.4 Counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6715.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


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Section 16: Traumatic Brain injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6816.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6816.2 Initial Assessment after concussion or mild TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6916.3 Follow-up for moderate and severe TBI (also relevant to concussion

with persistent symptoms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7016.3.1 Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

16.3.2 History and physical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7016.3.3 Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

16.4 Functional impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7116.5 Counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7216.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Section 17: Vascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7317.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7317.2 Arterial aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7317.3 Peripheral arterial vascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7417.4 Diseases of the veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Section 18: Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7518.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7518.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7518.3 Chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases . . . . . 7518.4 Permanent tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Section 19: Endocrine and metabolic disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7719.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7719.2 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

19.2.1 Diabetes not treated with insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7819.2.2 Diabetes treated with insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

19.3 Diabetic hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8019.4 Non-diabetic renal glycosuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8019.5 Non-diabetic hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.6 Thyroid disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.7 Parathyroid disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.8 Pituitary disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

19.8.1 Posterior deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.8.2 Anterior deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.8.3 Acromegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8119.8.4 Pituitary Tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

19.9 Adrenal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8219.9.1 Cushings disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8219.9.2 Addisons disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8219.9.3 Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Section 20: Renal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8320.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8320.2 Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

20.2.1 Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

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20.2.2 Peritoneal dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8420.3 Renal transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Section 21: Musculoskeletal disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8521.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8521.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

21.2.1 Injury to or immobilization of a limb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8621.2.2 Loss of limbs, deformities and prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8621.2.3 Arthritis, other musculoskeletal pain and ankylosis . . . . . . . . . . . . . . . . . . . . . . . . . . 8721.2.4 Injury to or immobilization of the spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8721.2.5 Post-orthopedic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Section 22: Miscellaneous conditions that may affect fitness to drive . . . . . . . . . . . . . . . . . . 9022.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9022.2 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9022.3 Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9022.4 General debility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9122.5 Common conditions may merit special consideration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Section 23: Anesthesia and surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9223.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9223.2 Outpatient surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9223.3 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9223.4 Major surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9223.5 Conscious sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Section 24: Seat belts and air bags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9324.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9324.2 Seat belts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

24.3 Air bags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9324.4 Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Section 25: Motorcycles and off-road vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9525.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9525.2 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9525.3 Specific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Section 26: Aviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9626.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9626.2 Aeronautics Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9626.3 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9726.4 Medical conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9726.5 General conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

26.5.1 Hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9726.5.2 Gas expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9826.5.3 Decompression illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9826.5.4 Tolerance to increased acceleration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9826.5.5 Spatial disorientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

26.6 Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

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26.7 Ear, nose and throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9826.8 Cardiovascular conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

26.8.1 Blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9926.8.2 Valvular heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9926.8.3 Congenital heart disease (CHD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9926.8.4 Cardiac arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

26.9 Cerebrovascular disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10026.10 Other vascular disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10026.11 Nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10026.12 Respiratory diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10126.13 Endocrine and metabolic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10126.14 Renal system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10126.15 Musculoskeletal system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10226.16 Psychiatric disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10226.17 Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10226.18 HIV infection and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10226.19 Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

26.20 Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Section 27: Railway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10427.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10427.2 Railway Safety Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10427.3 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10527.4 Medical fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10527.5 General considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10527.6 Specific issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10627.7 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10727.8 Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Appendix A: Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Appendix B: Fitness to drive issues and risk management messages from the CMPA . . . . . . . . . . . . . 118

Appendix C: The CAGE questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Appendix D:Alcohol use disorders identification test (AUDIT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Appendix E: Provincial and territorial contact information for reporting potentially unfit drivers . . . 124

Appendix F: Canadian Cardiovascular Societys risk of harm formula . . . . . . . . . . . . . . . . . . . . . . . . . 126

Appendix G: DSM-IV-TR criteria for substance abuse and criteria for substance dependence . . . . . . 128

Appendix H:American Society of Addition Medicine Definition of Addiction 2011 . . . . . . . . . . . . . 129

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1.1 A guide for physicians

The Canadian Medical Association (CMA) guide on the evaluation of fitness to drive has gained a global rep-utation since publication of the first edition in 1974. This 8th edition continues to provide physicians andmedical practitioners more generally with current, practical information about counselling patients on theeffects of their state of health on their fitness to drive.

With inclusion of a new section on dementia and mild cognitive impairment, the 8th edition recognizes

the demographic trends apparent in Canada as the baby boomers reach age 65 and the number of older driv-ers increases. Although some sections of the guide have no changes, those on aging, psychiatric illness, cere-brovascular diseases, traumatic brain injury, and musculoskeletal disabilities have undergone major revisions.Special attention has also been paid to the recent major revision by the Canadian Council of Motor Transport

Administrators (CCMTA) of its medical standards (formerly known as the medical standards of the NationalSafety Code) to ensure that the two publications contain similar recommendations when appropriate.However, it must be borne in mind that the context and considerations involved when a physician is coun-selling patients are not the same as those for an administrator who is determining driver licence status.Consequently, identical content for these two publications will never be possible.

The previous versions of the guide were as evidence based as possible, with each section author carryingout a literature search and supporting the submitted section with references. However, to save space in a guide

that was primarily distributed in print, the references were omitted from the final document, which left manyreaders with the false impression that the guidelines were based purely on consensus. To address this concern,the 8th edition includes a bibliography for the majority of sections (see Appendix A). In addition, CMAhopes to initiate a long-term project to identify levels of evidence for all of the practice guidelines, which maybe ready for inclusion in the next edition.

The major innovation for the 8th edition of the guide is that it has become a dynamic digital document.Although a print version will remain available, the digital version available on the CMA website will bereviewed at least annually. Users of the digital version will be asked to provide comments to improve theguide, and section authors will be asked to advise the editors when changes in practice guidelines in their spe-ciality affect content. The digital version of the guide will then be amended accordingly.

Hence, if you are holding a printed copy of the 8th edition as you read this introduction, you are advisedto check the online version to ascertain if the section of the guide that you wish to consult has been modifiedsince publication. In addition, the online version includes links to supporting documents, a bibliography andadditional information that could be useful in your practice.

1.2 Functional assessment

The 7th edition recognized that a landmark legal ruling British Columbia (Superintendent of Motor Vehicles)v. British Columbia (Council of Human Rights) had identified the right of Canadian drivers to have their

Section 1Introduction

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CMA drivers guide, 8th edition

2

licence eligibility determined on the basis of an individual functional assessment, rather than exclusively onthe basis of a diagnosis, with a corresponding responsibility for licensing authorities to accommodate driverswherever possible, within safe limits. This accommodation can often be achieved with appropriate licenceconditions or restrictions or vehicle modifications, which may be based on a physicians recommendation.Physicians should be aware of the need to review patients medical fitness to drive according to an assessment

of their overall functional capacity, including their ability to accommodate to medical and physical deficits.Physicians should also consider the possibility of synergetic effects of multiple medical conditions, as well asaging or other circumstances, on their patients overall functional capacity and fitness to drive.

The principle that it is the functional effects of the medical condition, rather than the diagnosis alone,that determine licence status in most cases. This principle is examined in detail in section 2 of the guide.

1.3 Medical standards for fitness to drive

Many of the recommendations in this guide are the same as the standards found in similar documents, suchas the CCMTA Medical Standards for Drivers. The CCMTA standards were developed in meetings of the med-ical consultants and administrators from each province and territory who are responsible for advising the

motor vehicle licensing authorities on medical matters and safety in driving. The CCMTA medical standardsare revised annually by that organizations Driver Fitness Overview Group, and the majority are adopted bythe provincial and territorial motor vehicle departments. This process achieves a uniformity of standardsacross Canada, with the result that a driver licensed in one province or territory can easily exchange his or herdrivers licence in the event of a move to another province and territory.

To minimize impediments to commercial drivers who must cross the CanadaUnited States border, anagreement has been reached whereby each country recognizes the medical standards of the other country. Theonly exceptions concern insulin-treated diabetes, epilepsy, hearing deficits and drivers with medical waivers.Canadian commercial drivers with these conditions and those with a medical waiver cannot cross the borderto the United States with their commercial vehicles. Private drivers and commercial drivers who are drivingprivate vehicles are not affected by this measure.

1.4 Methods

To produce this edition, the CMA undertook an evidence-based review of medical standards under the leader-ship of a Scientific Editorial Board, comprising five member physicians and an editor-in-chief with a range ofrelevant practice and advisory experience pertaining to driver fitness and safety. The editorial board workedwith the 2006 CMA publication Determining Medical Fitness to Operate Motor Vehicles: CMA Drivers Guide(7th edition) to produce a draft for this new edition. Some sections were written or edited by selected physi-cians with expertise in the clinical field, whereas others reflect consensus documents from specialty societies.The draft was widely circulated to medical and non-medical organizations, provincial driving authorities andselected experts. All comments were considered by the Scientific Editorial Board.

Although there is still comparatively little scientific evidence available to assess the degree of impairmentto driving that results from many medical disabilities, the evidence is increasing. The Scientific EditorialBoard was aided in the preparation of this guide by a review of recent scientific reports for each section.Interested readers are referred to a study undertaken by the Monash University Accident Research Centre,entitled Influence of Chronic Illness on Crash Involvement of Motor Vehicle Drivers 2nd edition,November 2010 which is the most complete and detailed review of the evidence supporting medical stan-dards for drivers at the time of publication of this guide. The 2009 National Highway Traffic Safety

Administration (NHTSA) publication Driver Fitness Medical Guidelinesis another useful publication that


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Determining medical fitness to operate a motor vehicle

contains both extensive references and an analysis of the literature. In addition, a risk of harm formula thatwas introduced in the 7th edition, to support the Canadian Cardiovascular Society recommendations on fit-ness to drive (section 14), has been retained in this edition. However, the recommendations remain mainlyempirical and reflect the fact that the guidelines presented here are based on the consensus opinion of anexpert panel supported by a careful review of the pertinent research and examination of international and

national standards, as well as the collected experience of a number of specialists in the area. They are intend-ed to impose no more than common sense restrictions on drivers with medical disabilities. This guide is nota collection of hard-and-fast rules, nor does it have the force of law.

1.5 The physicians role

Physicians are regularly called upon to evaluate medical fitness to drive. Traditionally, this occurs when apatient arrives with the dreaded driver fitness form from the licensing authority. However, in many parts ofCanada, driving is a daily activity, and the potential effects of a medical condition on driving capability shouldbe a consideration for everyone, regardless of age or whether they have a driver fitness form to be completed.For instance, a person with newly diagnosed diabetes should receive counselling on the Canadian Diabetes

Associations recommendations for drivers, along with advice about diet and exercise. This observation appliesto all medical conditions and to all patients with a drivers licence, although very few physicians routinelyinquire about licence status.

Every physician who examines a patient to determine fitness to drive must always consider both theinterests of the patient and the welfare of the community that will be exposed to the patients driving. In thecourse of the examination, the physician should not only look for physical disabilities but also endeavour toassess the patients mental and emotional fitness to drive safely. A single major impairment or multiple minorfunctional defects may make it unsafe for the person to drive. Adaptations to the vehicle or changes in drivinghabits allow compensation for most physical limitations, but in most cases, cognitive limitations are notamenable to compensation.

Likewise, physicians should be aware of their responsibility or legislated requirement to report patients

with medical conditions that make it unsafe for them to drive, according to the jurisdiction in which theypractise. Physicians should also be aware of the circumstances in which patients are likely to function. Forexample, the extreme demands related to operating emergency vehicles suggest that drivers of these vehiclesshould be cautioned that even relatively minor functional defects may make it unsafe for them to drive.

1.6 Public health

Motor vehicle crashes kill about 2,500 people in Canada each year and injure another 180,000. By contrast,the number of deaths attributable to SARS in 2003 was 44, the number of deaths from West Nile Virus from20022005 was 46, and 158 Canadian soldiers were killed in Afghanistan 20022011.

Most motor vehicle crashes involve people between the ages of 15 and 55 years. Crashes are a leadingcause of death and disability in these age groups. Major contributing factors to crashes involving younger peo-ple are alcohol, speeding and poor judgment, including driving inappropriately for weather and road condi-tions and failure to use safety equipment. Older drivers are involved in proportionally fewer crashes thanyounger drivers, but they are more likely to die in a crash, principally because of increased frailty.

Anything that physicians can do to encourage safe driving by their patients has a positive public healthimpact. Questions regarding drinking and driving and seat belt use should be considered at least as importantas questions regarding smoking behaviour. The prevention of motor vehicle crashes has at least as great animpact on population health as trauma programs that treat crash victims. The health of commercial drivers is

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also an important consideration, given their long hours on the road and their vulnerability to metabolic disease,fatigue and stimulant use. It is imperative that physicians understand the increased risks associated withobstructive sleep apnea, cardiovascular diseases, addictions and other conditions that may reduce driver fitness.

1.7 Levels of medical fitness required by the motor vehicle licensing authorities

The motor vehicle licensing authorities have the power to issue and suspend licences. Legislation in theprovincial and territorial jurisdictions stipulates that these authorities can require licensed drivers to be exam-ined for their fitness to drive. Fitness is considered to mean fitness in the medical sense. The provincial andterritorial motor vehicle licensing authorities have the final responsibility for determining licence eligibility,and fitness to drive is a major determinant of eligibility. The recommendations of the CMA outlined in thisguide are meant to assist physicians in counselling their patients about the effects that their medical condi-tions will have on their fitness to drive and how to minimize these effects. The guide will also help physiciansin determining whether a person is medically fit and to identify conditions that will likely disqualify a personfrom holding a licence.

The classification of drivers licences does not take into account the context of driving activities, nor do

licensing authorities regulate driving activity for most drivers. However, the amount driven and the environ-ment in which driving takes place are important predictors of risk. This guide refers to private and com-mercial drivers with various recommended standards of fitness. Drivers of vehicles for which a Class 5 licenceis applicable may be considered commercial drivers on the basis of the amount driven. Physicians shouldassess their patients for fitness to drive in the context in which they will be driving and advise them according-ly. Obviously, for a patient with a known risk of a medical event, the risk of the event occurring while the per-son is at the wheel will be much greater if the person spends much of the day at the wheel than if the personrarely drives.

The motor vehicle licensing authorities require a higher level of fitness for commercial drivers who oper-ate passenger-carrying vehicles, trucks and emergency vehicles. These drivers spend many more hours at thewheel, often under far more adverse driving conditions, than drivers of private vehicles. Commercial drivers

are usually unable to select their hours of work and cannot readily abandon their passengers or cargo shouldthey become unwell while on duty. Commercial drivers may also be called upon to undertake heavy physicalwork, such as loading or unloading their vehicles, realigning shifted loads and putting on and removingchains. In addition, should the professional driver suffer a collision, the consequences are much more likely tobe serious, particularly when the driver is carrying passengers or dangerous cargo. People operating emergencyvehicles are frequently required to drive under considerable stress because of the nature of their work.Inclement weather, when driving conditions are less than ideal, is often a factor. This group should also beexpected to meet higher medical standards than private drivers.

It should also be borne in mind that operators of heavy machinery, such as front-end loaders, may hold aClass 5 (private vehicle) licence, rather than the higher classes of licence normally required for commercialdrivers. Alternatively, a patient with this class of licence may be a commercial traveller who drives thousandsof kilometres a week in an automobile.

1.8 Drivers medical examination report

If, after completing a drivers medical examination, a physician is undecided about a patients fitness to drive,the physician should consider arranging a consultation with an appropriate specialist. A copy of the specialistsreport should accompany the medical form when it is returned to the motor vehicle licensing authority.

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Alternatively, physicians may consider referring a patient to a driver assessment centre if a functional assess-ment is beyond the scope of the examining physician.

A medical examination is mandatory for some classes of licences. The licensing authority may base a finaldecision regarding a drivers licence eligibility on the examining physicians opinion. When the report differssignificantly from previous reports submitted by other physicians or conflicts with statements made by the

driver, the motor vehicle licensing authority will often ask its own medical consultants for a recommendation.Ultimately, it is the licensing authority, not the physician, that makes the final determination of eligibili-ty. Some jurisdictions have ceased to ask the physicians opinion as to the drivers fitness to drive, since it canbe difficult to extrapolate office observations to actual driving conditions. In these jurisdictions, the physiciansresponsibility is to provide accurate information that will permit the licensing authority to make the appropri-ate decision. Obviously, awareness of the individual jurisdictions approach and standards is essential for anyphysician who is assessing and evaluating patients medical fitness to drive.

1.9 Physician education on driver evaluation

Most medical school curricula spend little, if any, time on driver evaluation. As a result, most physicians have

only a passing knowledge of many of the aspects discussed in this guide. Although the guide can be useful inaiding physicians to become familiar with evaluating drivers fitness, availability of and participation in formalcontinuing medical education programs are essential if physicians wish to improve their knowledge of thesubject. The benefits of interaction with a knowledgeable physician who can explain how the licensingauthority applies the principles described in this guide and in the CCMTA Medical Standards for Drivers, aswell as the particularities of the respective jurisdictions rules and regulations, cannot be duplicated in a print-ed document.

Some Canadian jurisdictions already offer such continuing education programs, which have proven pop-ular with physicians. Physicians are encouraged to attend such programs if available in their respective juris-dictions or to request them if not available.

1.10 Payment for medical and laboratory examinations

Since driving is considered a privilege, in most jurisdictions patients are responsible for paying for all medicalreports and laboratory examinations carried out for the purpose of obtaining or retaining a drivers licence,even though the examinations or tests may have been requested by the motor vehicle licensing authority. Inother provinces, examinations for some drivers, such as seniors, are insured services, or it is the responsibilityof drivers employers to cover such costs. Functional evaluations are often at the drivers cost.

1.11 Classes of drivers licences and vehicles

Drivers licences are divided into classes according to the types of motor vehicles that the holder is permittedto drive. The classifications can vary across jurisdictions, and graduated licensing systems have beeninstituted in some jurisdictions. In this guide, therefore, licences and vehicles are classified generically,and readers should refer to the provincial or territorial classification when necessary(see Appendix Efor contact information).

Class 1: Permits the operation of an articulated truck.

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Class 2: Permits the operation of a bus carrying 25 passengers or more.

Class 3: Permits the operation of a non-articulated truck.

Class 4: Permits the operation of a taxicab, a bus carrying no more than 24 passen-gers and emergency response vehicles, such as ambulances, fire trucks and police cars.

Class 5: Permits the operation of any two-axle motor vehicle or a two-axle vehicle

and a trailer, so long as the combined weight does not exceed 4,600 kg. In some jurisdictions, a Class 5licence permits the holder to drive an ambulance, a taxicab or a bus with no passengers on board. Heavyequipment, such as graders and other road-building equipment with two axles, is also covered by the Class 5licence.

Class 6: Permits the operation of a motorcycle, motor scooter or mini-bike only. Allother classes of licence must be endorsed to include Class 6 vehicles before the holder may operate a motorcy-cle, motor scooter or mini-bike.

1.12 Contact us

This guide is produced as a service to CMA members. However, the CMA does not have the capacity to com-ment on or respond to questions related to clinical issues arising from the work of the content experts.

Physicians who have comments and suggestions about the guides recommendations are invited tocontact the Canadian Medical Association at [email protected] or toll free at 888-855-2555.

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2.1 OverviewHistorically, determining medical fitness to drive was based solely on a medical office examination and a diag-nosis. However, recent court decisions have recognized that a drivers ability to accommodate and functionwith a given medical condition varies with the individual.

These court decisions have also established the right of individuals to be assessed individually for theirability to drive safely. A functional assessment, which is a structured assessment of the individuals ability toperform the actions and exercise the judgment necessary for safe driving, often including a road test, takes this

individual variation into account. Functional assessments are usually administered by occupational therapists(find an occupational therapist*), although some jurisdictions may have driving rehabilitation specialists whocan perform on-road assessments. Some jurisdictions perform their own on-road assessments of driving fitnessbut these tests are usually less comprehensive than those performed by occupational therapists. In particular,only occupational therapists can assess the requirements for modifications to vehicles that are needed toaccommodate drivers with a physical disability.

A driver with a medical condition that can compromise cognitive or motor skills may require a functionalassessment to determine fitness to drive. Any compromise of the ability to perform daily activities or of the driversautonomy should trigger some sort of functional driving assessment.

Functional assessments may be available only in urban centres and may be difficult to arrange for patientsin rural areas.

2.2 Standards

Canadian jurisdictions are working to develop and apply standards that permit individual assessment offunctional capabilities of drivers with medical conditions that may affect driving.

Medical standards for drivers must address three types of conditions:

Section 2Functional assessment

emerging emphasis

7

Alert box

Medical standards for drivers often cannot be applied without considering the functional impact ofthe medical condition on the individual.

All Canadian jurisdictions have policies in place that allow individuals the opportunity to demon-strate that they are capable of driving safely despite the limitations implied by a diagnosis. Criteria

may vary among jurisdictions.

* www.caot.ca/default.asp?pageid=3622


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8

Functional or permanent limitations: Certain medical conditions, or combinations of medical conditions,can lead to limitations of functional capabilities (e.g., amputation of a foot will affect the persons abilityto drive a vehicle with manual transmission).

Associated risk or episodic limitations: The risk of a catastrophic event due to a medical condition may bejudged to be unacceptable. Certain heart conditions are examples of medical conditions where the risk

that an incapacitating event will occur while driving has led to the definition of criteria designed todiminish the risk.Use of substances judged incompatible with driving: Illicit drugs, alcohol and medications may interfere

with fitness to drive.

2.3 Assessment

2.3.1 Office assessmentPhysicians in a medical office setting can assess their patients fitness to drive when the patients are clearlyeither capable or incapable of driving. This guide provides information to assist with those decisions. In lessclear-cut situations, it may be necessary for the physician to employ other means of testing to perform a func-

tional assessment. This usually involves on-road testing.It should be emphasized that, with the exception of temporary restrictions for short-term medical situa-

tions, the physician is not required to determine whether a licence will be granted or suspended. The physi-cians responsibility is to describe the situation, and the licensing authority will make a decision based on thephysicians observations, other available information (such as police reports) and its interpretation of the regu-lations.

2.3.2 Functional assessmentA functional assessment is appropriate when the medical condition in question is present at all times.Functional assessment is not appropriate when the driver has a medical condition that is episodic (e.g.,seizures) and known to be associated with increased risk.

Licensing authorities make their own decisions about the evidence and opinions on which to base theirdecisions. There is a role for specialized road testing and computerized screening, as well as some self-adminis-tered tests (as long as the patient has insight). Physicians may choose to refer a patient for additional assess-ment when such resources are available.

The decision to refer for assessment can be deferred to the licensing authority. Assessments are usuallyavailable through private companies and are paid for by the driver. Some public health care facilities offerdriving assessments free of charge, but access is limited and waiting lists tend to be long.

Some jurisdictions use off-road evaluations, such as driving simulators or batteries of tests, to predicton-road behaviour. Computerized testing may provide useful objective information about functions believedto be important for safe driving. However, there is insufficient evidence either to support or refute makinglicensing decisions based solely on their results.

Most Canadian jurisdictions have some form of formal road testing in place, often conducted by occupa-tional therapists specialized in the functional testing of drivers. In some jurisdictions, certified technicians dothe testing. Assessments are typically limited to drivers of private cars. Drivers of commercial vehicles andmotorcycles usually cannot be evaluated in private centres, although some specialized centres have developedtesting for drivers of these vehicles.

Currently, there is insufficient evidence to recommend for or against any specific testing method, althoughauthoritative research in this field has demonstrated clearly that the novice drivers road test is inappropriate forexperienced drivers. Any road test for experienced drivers must include driving in unfamiliar surroundings, to


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test how the driver reacts to situations that differ from his or her daily routine. Although use of the drivers ownvehicle may reduce the level of stress, difficulty driving an unfamiliar vehicle may indicate cognitive inflexibilitythat could have a negative effect upon fitness to drive. Geographic limitations (i.e., restricting drivers to theirlocal area) are not recommended for drivers with cognitive problems, especially those with dementia. In fact,recent guidelines on dementia recommend that any driver with dementia who requires the imposition of

licence restrictions to ensure driving safety should be suspended from driving completely.

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3.1 Overview

All provinces and territories impose a statutory duty on physicians relating to the reporting of patientsdeemed unfit to drive. This duty may be mandatory or discretionary, depending on the jurisdiction (seeTable 1). The duty to report prevails over a physicians duty of confidentiality. Section 35 of the CMACodeof Ethicsaffirms the notion that physicianpatient confidentiality may be breached when required or permit-ted by law:

Disclose your patients personal health information to third parties only with their consent, or as

provided for by law, such as when the maintenance of confidentiality would result in a signifi-cant risk of substantial harm to others or, in the case of incompetent patients, to the patientsthemselves. In such cases take all reasonable steps to inform the patients that the usual require-ments for confidentiality will be breached.

Section 3Reporting when and why*

10

Alert box

Physicians have a statutory duty to report patients whom they believe to be unfit to drive to the relevantprovincial or territorial motor vehicle licensing authority. This duty may be mandatory or discretionary,depending on the province or territory involved. This duty to report is owed to the public and supersedesthe physicians private duty with regard to confidentiality.

*This section is meant for educational purposes, as a guide to physicians on reporting of patients assessed to be unfit to drive. It is not meantto replace legal counsel. Unless specified, this section refers to fitness to drive motor vehicles.

Pilots, air traffic controllers and certain designated railway workers are governed by federal legislation that requires the reporting of certain

individuals in these transportation industries who have a medical condition rendering them unfit to perform their duties. These reporting obliga-tions are discussed in separate sections of this guide (sections 26 and 27). The marine working environmentis challenging with safety-criticalresponsibilities and the presence of many hazards including a strenuous workplace, unique living conditions, unpredictable weather andpotential emergency duties. Seafarers must be able to live and work in close contact with each other for long periods. The difficulties of thisenvironment can be magnified when medical care is not immediately accessible when needed. For this and other reasons, since 2001, theCanada Shipping Actrequires physicians and optometrists to report to Transport Canada Marine Safety and Security without delay when theyhave reasonable grounds to believe that a seafarer has a medical or optometric condition that is likely to constitute a hazard to maritime safe-ty. This same law requires cer tificated Seafarers to inform their caregivers of their safety critical role. Further information can be found on lineat www.tc.gc.ca/eng/marinesafety/mpsp-training-examination-certification-medical-2058.htm or contact Marine Medicine at 866 5777702 for assistance.


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instances where a patients fitness to drive is impaired for a brief period, such as a few days or immediatelyafter the patient has undergone a medical test, physicians might wonder whether a report to the motor vehiclelicensing authority is warranted, given the time lag of licence revocation. At a minimum, the physician shouldcaution the patient not to drive for the duration of the temporary impairment and should document thesediscussions. If the physician in unsure about the proper course of action in such situations, he or she should

consult the CMPA.In general, physicians should err on the side of reporting any potentially medically unfit driver. This isespecially important in jurisdictions where there is a mandatory reporting obligation. Physicians shouldcontact the provincial or territorial motor vehicle licensing authority for details on the process for reporting intheir respective jurisdictions (see Appendix E). Physicians are encouraged to contact the CMPA for assistancein interpreting the jurisdictional standards.

Once the physician has made a report to the licensing authority, he or she has discharged his or her legalresponsibility. Subsequently, should the physician become aware that a driver whose privileges are known tohave been suspended is continuing to drive, the physician has no legal obligation to report the situation to anyauthority, such as the motor vehicle licensing authority or the police. However, there are ethical considera-tions, in that an unsafe driver may pose a hazard to the health of other road users. This is a complex issue, and

neither legislation nor existing ethical codes provide specific guidance to negate the legal or regulatory risks. Insuch a situation, the physician is advised to contact the CMPA for advice and to document the reasons fordeciding whether or not to make a follow-up report.

Physicians should also contact the CMPA if a patient threatens legal action for making a report to thelicensing authority.

3.3 Patients right of access to physicians report

The right of patients to access reports about fitness to drive made to the motor vehicle licensing authority andany notes made in the medical chart about such a report is subject to provincial/territorial legislation.Physicians should contact the CMPA for further information specific to their jurisdiction.

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Table 1: Regulations governing reporting of medically unfit drivers and protection for physicians (current as of June2012)

Jurisdiction ReportingMD protectionfor reporting

Admissibility of reports as evidence in legalproceedings*

Alberta Not directly addressed, butinterpreted as discretionary Protected Reports confidential

British Columbia Mandatory for MD ifthe unfit driver has beenwarned of the danger andstill continues to drive

Protected unless physician actsfalsely or maliciously Not addressed

Manitoba Mandatory Protected PrivilegedNot admissible as evidence except to provecompliance with reporting obligations

New Brunswick Mandatory Protected as long as physicianacts in good faith Not addressed

Newfoundlandand Labrador Mandatory Protected PrivilegedNot admissible in evidence at trial except to

prove compliance with reporting obligationsNorthwestTerritories

Mandatory Protected unless physician actsmaliciously or withoutreasonable grounds

Not admissible in evidence or open to publicinspection except to prove compliance with thereporting provision and in a prosecution of acontravention of section 330 (making falsestatements or submitting false documents). Theperson who is the subject of the report is entitledto a copy of the report upon payment of aprescribed fee.

Nova Scotia Discretionary Protected Not addressedNunavut Mandatory Protected unless physician acts

maliciously or withoutreasonable grounds

Not admissible in evidence or open to publicinspection except to prove compliance with thereporting provision and in a prosecution of acontravention of section 330 (making falsestatements or submitting false documents). Theperson who is the subject of the report is entitledto a copy of the report upon payment of aprescribed fee.

Ontario Mandatory Protected PrivilegedNot admissible in evidence except to provecompliance with reporting obligations

Prince EdwardIsland

Mandatory Protected PrivilegedNot admissible in evidence except to provecompliance with reporting obligations

Quebec Discretionary Protected Not admissible in evidence except in cases ofjudicial review of certain decisions of the motorvehicle licensing authority

Saskatchewan Mandatory Protected as long as physicianacts in good faith PrivilegedNot admissible in evidence except to show that

the report was made in good faith inaccordance with reporting obligationYukon Mandatory Protected Not addressed

*Information in this column is subject to the access-to-information legislation of the respective province or territory.

Pending legislation in British Columbia will change the province from a mandatory reporting province to a hybrid mandatory/discretionaryreporting province.

Note: MD = physician.


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4.1 Overview

Driving plays a central role in the daily lives of many people, not only as a means of meeting transportationneeds, but also as a symbol of autonomy and competence. The prerogative to drive often is synonymous withself-respect, social membership and independence.

Driving cessation can result from a gradual change in driving behaviour (i.e., restrictions leading to driv-ing cessation), a sudden disabling event (e.g., a stroke) or a progressive illness (e.g., dementia). However, thedecision to stop driving is often complex and affected by a number of factors. Some drivers voluntarily stopdriving; for others, driving cessation is involuntary.

4.2 Voluntary driving cessation

Voluntary driving cessation refers to self-induced changes in driving practices that are made for reasons otherthan the revocation of a licence or other strong influence from external sources. A number of general factorsare associated with voluntary driving cessation. Age older people are more likely to stop driving of their own accord. Gender women are more likely to give up driving voluntarily. Marital status those who are single, widowed or divorced are more likely to stop driving than those

who are married. Socio-economic status those with lower income are more likely to stop driving. Education people with lower levels of education are more likely to stop driving. Place of residence urban dwellers are more likely to stop driving than those living in rural areas.

These general factors can assist physicians in anticipating who may be more comfortable giving up driv-ing privileges when it becomes medically advisable to stop driving.

4.3 Involuntary driving cessation

Involuntary driving cessation occurs when a licence is revoked or outside sources (physician, family members)bring their influence to bear. Involuntary driving cessation often is due to the presence of one or more med-ical conditions or the medications used to treat those conditions.

Section 4Driving cessation

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Alert box

Despite research showing that life expectancy exceeds driving expectancy by 9.4 years for women and6.2 years for men, most current drivers do not plan well for driving cessation.


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The most difficult situation physicians face is when a patient is functionally incapable of driving safely,but perceives him- or herself as competent to drive. Physician interventions include frank but sensitive discus-sions with the patient (with or without the patients family present), referral for a driving evaluation andreporting to the licensing authority. Counselling on alternative means of mobility is needed. For those withcognitive impairment, through the door service, as opposed to regular door to door public transportation,

will be needed. For progressive illnesses (e.g., dementia, macular degeneration, multiple sclerosis), early discus-sions can help the person and his or her family to plan for the inevitable need to stop driving.Involuntary driving cessation is more likely to be required when awareness of ability declines or is

impaired (e.g., with dementia). To date, only a few factors are known to be associated with involuntary driv-ing cessation. Gender men are more likely to require outside intervention to cease driving. Insight those with impaired insight are more likely to continue to drive and require intervention.

These factors can assist physicians in predicting who may be resistant to discussions about the need fordriving cessation or who will be resistant to and non-compliant with advice or a directive to stop driving. Inaddition to patients, families also may lack insight into the negative impact of an illness on driving. Familymembers may have their own reasons for wanting the person to continue driving (e.g., loss of mobility for the

patient and often the spousal caregiver, time demands associated with a family member becoming the trans-portation provider, increased caregiver burden). Education and support for caregivers and other family mem-bers frequently are necessary.

Specialized support groups have been shown to be effective in helping patients and caregivers in copingwith the loss of driving privileges. Such groups may be available to assist patients (and their caregivers) in thetransition from being a driver to being a non-driver.

4.4 Planning for retirement from driving

Few drivers plan for retirement from driving. However, data indicate that, on average, men outlive their driv-ing careers by 6.2 years and women by 9.4 years. Incorporating driving retirement plans with financial plan-

ning for retirement may be an effective means of engaging both current and future cohorts of drivers in plan-ning for the day when they will no longer drive. In addition to assistance from family and friends, responsiveforms of alternative transportation are needed to allow those who have retired from driving to remain engagedwith their community. However, most forms of public transportation (e.g., light rail transit, public buses) aredesigned primarily for individuals who are relatively healthy and mobile. Ensuring the availability of alternativetransportation that is responsive and accommodating to patients who wish not to or can no longer drive (e.g.,volunteer driver programs, for-profit services such as Driving Miss Daisy) is critical to meeting the needs of thisgrowing segment of the population. Physicians can play an important role in helping patients and their familiesto become familiar with the transportation resources available in their communities.

4.5 Strategies for discussing driving cessation*It is important to recognize the consequences of driving cessation for both patients and families.

The following suggestions will help physicians to develop a strategy before meeting with the patient todiscuss driving cessation. Before the appointment, consider the patients impairments. It may be important to ask if the spouse or

another caregiver can be present. This can provide emotional support and help to ensure that the family

*Adapted from Clinical engagement of medically at-risk driving. Edmonton, AB: Pallium Project; 2006.

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5.1 Overview

Alcohol is a depressant drug that has both sedative and disinhibitory effects. It also impairs a drivers judg-ment, reflex control and behaviour toward others. Impairment from alcohol use is the single most commonrisk factor for motor-vehicle-related crashes and injury.

Traditionally, diagnoses of alcohol abuse and alcohol dependence, based on Diagnostic and StatisticalManual of Mental Disorders, fourth edition (DSM-IV-TR) criteria (Appendix G), have been used to identifydrivers who may require intervention (see section 5.2.2, Screening tools). However, these diagnostic criteriaalone may not correlate with behaviour suggestive of functional impairment when driving.

People charged by police for impaired driving will have their driving privileges restricted according toprovincial legislation. The guidelines provided here are not meant to conflict with such legislation.

In some people who are regular users of alcohol, withdrawal from alcohol may trigger seizures. Forseizures induced by alcohol withdrawal, see section 11.4.7.

5.2 Assessment

5.2.1 Clinical historyResearchers have identified a group of drivers (often referred to as hard-core drinking drivers) who drivewith blood alcohol levels averaging twice the legal limit, have previous driving convictions and licence suspen-sions, may drive without a valid driving licence and likely need treatment for alcohol dependence.

A number of clinical red flags have been identified, which may indicate ongoing alcohol use that willimpair ability to drive safely. These indicators include driver with at least one previous driving offence, especially an alcohol- or drug-related offence driver arrested with blood alcohol concentration of 32.6 mmol/L (equivalent to 0.15% or 150 mg/100 mL)

or more (the low risk of detection implies that they have probably driven in this condition previously) clinical diagnosis of alcohol dependence or abuse resistance to changing drinking-and-driving behaviour, often associated with antisocial tendencies such as

aggression and hostility

Section 5Alcohol

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Alert box

Acute impairment is an immediate contraindication to driving. Patients suspected of alcohol dependence or abuse should be assessed to determine the nature of the

problem and should be advised not to drive until the condition has been effectively treated and remis-sion has been achieved.


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5.2.2 Screening toolsTools to screen for alcohol dependence and abuse include the CAGE questionnaire (Appendix C) and

AUDIT, a 10-question alcohol use disorder identification test (Appendix D). AUDIT detects both excessivedrinking and the symptoms of abuse and dependence.

The DSM-IV-TR lists the criteria for diagnosis of substance abuse and substance dependence

(Appendix G). The major medical criteria for the diagnosis of alcohol dependence are impaired control andcompulsive behaviour related to alcohol ingestion, as well as continued use despite the presence of clinicalconsequences of excessive alcohol use. Alcohol-related problems must be considered in the context of the lat-est definition of addiction, as established by the American Society of Addiction Medicine and adopted by theCanadian Society of Addiction Medicine (Appendix H).

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6.1 Overview

Patients taking illicit, non-prescription or prescription drugs known to have pharmacologic effects or sideeffects that can impair the ability to drive should be advised not to drive until their individual response isknown or the side effects no longer result in impairment (e.g. patients stabilized on chronic opioid therapy forchronic pain or opioid dependence). Keep in mind that drugs can have unexpectd adverse effects as well,which may affect ability to drive.

Concomitant use of several drugs (e.g., alcohol combined with antihistam

cma drivers guide

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